影响缺血性心肌病血运重建后左心室射血分数的多因素分析

Multiple factors analysis on the recovery of left ventricular ejection fraction in the revascularized patients with ischaemic cardiomyopathy

目的探讨如何筛选出血运重建后左心室射血分数(LVEF)明显增加的缺血性心肌病(ischaemic cardiomyopathy,ICM)患者。方法回顾性分析我院2010年7月至2015年12月期间,245例行冠状动脉旁路移植术(coronary bypass grafting,CABG)(30%≤LVEF≤40%),其中合并缺血性二尖瓣反流146例(146/245,59.6%),有41例患者因中度以上的缺血性二尖瓣反流而同时行二尖瓣成形术/置换术。围术期死亡13例(12例为CABG+二尖瓣成形术或置换术,1例为单纯行CABG术),余232例随访6个月以上为研究对象,根据术后LVEF是否增加10%分为两组,即LVEF恢复组(A组)124例,LVEF不恢复组(B组)108例。结果单因素分析发现A组术前NT-proBNP值明显高于B组(P=0.036),有心肌梗死病史的比例明显低于B组(P=0.047),而术前仍有心绞痛的比例明显高于B组(P=0.024)。两组之间的二尖瓣反流程度及二尖瓣成形术或置换术比例差异无统计学意义(P=0.199)。A组患者的左心室舒张期末内径(LVEDD)、左心室收缩期末内径(LVESD)、左室舒张期末容积(LVEDV)均明显低于B组(P<0.05)。多因素分析发现LVEDD明显增大、术前无明显心绞痛是ICM(30%≤LVEF≤40%)患者行血运重建后LVEF不能恢复的术前危险因素。以245例患者(包括13例围术期死亡患者)为研究对象,其LVEDD为41～71 mm,发现LVEDD≥60 mm与ICM患者的预后不良有显著关系(χ2=8.63,P=0.003,OR=2.21,95%CI 1.25～3.91)。结论发现LVEDD明显增大、术前无明显心绞痛是ICM(30%≤LVEF≤40%)患者行血运重建后LVEF不能恢复的术前危险因素。LVEDD≥60 mm可以作为ICM(30%≤LVEF≤40%)患者预后不良的术前临床筛选指标之一。

Objective We probed how to predict left ventricular ejection fraction(LVEF) of the ischaemic cardiomyopathy(ICM) patients would be improved apparently after revascularization. Methods Between July 2010 and December 2015, 245 ICM patients(30%≤LVEF≤40%) with coronary bypass grafting(CABG) were retrospectively observed. Among them, 146 patients were accompanied by ischemic mitral regurgitation(IMR)(146/245, 59.6%), and 41 patients underwent mitral valvuloplasty or replacement because of more than moderate IMR. There were 13 patients early death, and other 232 patients who were followed up over 6 months were divided into two groups based on whether or not post-operative LVEF increased by 10%: a LVEF recovered group(group A, 124 patients) and a non-recovered group(group B, 108 patients). Results Preoperative NT-proBNP in the group A was significantly higher than that in the group B(P=0.036). There were less patients with myocardial infarction in the group A than that in the group B(P=0.047), and more with angina pectoris in the group A than that in the group B(P=0.024). There was no significant difference in the extent of mitral regurgitation or mitral surgery between the groups A and B(P>0.05). There were lower left ventricular end-diastolic diameter(LVEDD), left ventricular end-systolic diameter(LVESD) and left ventricular end-diastolic volume(LVEDV) in the group A than those in the group B(P<0.05). Multivariate analysis revealed that preoperative LVEDD dilated apparently and no angina pectoris existed before surgery were independent risk factors for LVEF with no recovery in the ICM patients(30%≤LVEF≤40%) after revascularization. The LVEDD of 245 patients(including 13 early deaths)was 41-71 mm. We found that the ICM patients with LVEDD ≥60 mm were more likely to signify the unfavourable prognosis(χ2=8.63, P=0.003, OR=2.21, 95% confidence interval 1.25 to 3.91). Conclusion Preoperative LVEDD dilated and no angina pectoris before surgery are independent risk factors for LVEF with no recovery in the ICM patients(30%≤LVEF≤40%) after revascularization. LVEDD≥60 mm can be regarded as the preoperative forecasting factors for the unfavourable prognosis in the ICM patients(30%≤LVEF≤40%) after revascularization.